Member Handbook for Parkland KIDSfirst and Parkland CHIP ...

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Type of Benefit Description of Benefit Limitations Co-Pay • Orthotic braces and orthotics • Prosthetic devices such as artificial eyes, limbs and braces • Prosthetic eyeglasses and contact lenses for the management of severe ophthalmologic disease • Hearing aids • Diagnosis-specific disposable medical supplies, including diagnosis-specific prescribed specialty formulas and dietary supplements Home and Community Health Services Inpatient Mental Health Services Medically necessary services are provided in the home and community and include, but are not limited to: • Home infusion • Respiratory therapy • Visits for private duty nursing (R.N., L.V.N.) • Skilled nursing visits as defined for home health purposes (may include R.N. or L.V.N.). • Home health aide when included as part of a plan of care during a period that skilled visits have been approved • Speech, physical and occupational therapies. Medically necessary services include, but are not limited to: • Mental health services furnished in a freestanding psychiatric hospital, psychiatric units of general acute care hospitals and stateoperated facilities. • Neuropsychological and psychological testing. PKF-M100708R 15 • Requires authorization and physician prescription • Services are not intended to replace the child's caretaker or to provide relief for the caretaker • Skilled nursing visits are provided on intermittent level and not intended to provide 24-hour skilled nursing services • Services are not intended to replace 24-hour inpatient or skilled nursing facility services • Requires prior authorization for non-emergency services • Does not require PCP referral. • Inpatient mental health services are limited to: • 45 days 12-month period inpatient limit • Includes inpatient psychiatric services, up to 12-month period limit, ordered by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health • No Co-pays required for CHIP or CHIP Perinate Newborn Members • Applicable level of inpatient copay applies for CHIP Members • No copays required for CHIP Perinate Newborn Members
Type of Benefit Description of Benefit Limitations Co-Pay and Safety Code, relating to court ordered commitments to psychiatric facilities. Court order serves as binding determination of medical necessity. Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination. • 25 days of the inpatient benefit can be converted to residential treatment, therapeutic foster care or other 24-hour therapeutically planned and structured services or subacute outpatient (partial hospitalization or rehabilitative day treatment) mental health services on the basis of financial equivalence against the inpatient per diem cost • 20 of the inpatient days must be held in reserve for inpatient use only Outpatient Mental Health Services • Medically necessary services include, but are not limited to, mental health services provided on an outpatient basis. • Medication management visits do not count against the outpatient visit limit. • Neuropsychological and psychological testing. PKF-M100708R 16 • Requires prior authorization. • Does not require PCP referral. • The visits can be furnished in a variety of communitybased settings (including school and home-based) or in a state-operated facility. • Up to 60 days 12-month period limit for rehabilitative day treatment. • 60 outpatient visits 12-month period limit • 60 rehabilitative day treatment days can be converted to outpatient visits on the basis of financial equivalence against the day treatment per diem cost. • 60 outpatient visits can be converted to skills training (psycho educational skills development) or rehabilitative day treatment on the basis of financial • Applicable level of copay applies to office visits for CHIP Members. • No co-pays required for CHIP Perinate Newborn Members.
Page 1 and 2: This book belongs to:______________
Page 3 and 4: WELCOME TO OUR PARKLAND KIDSfirst a
Page 5 and 6: ‣ We may provide information to a
Page 7 and 8: If you believe your privacy rights
Page 9 and 10: • What if I/my child has an emerg
Page 11 and 12: The Member ID is the same as your c
Page 13 and 14: How Do I Choose My Child's Primary
Page 15 and 16: You will get a letter in the mail i
Page 17 and 18: Parkland CHIP Perinate Newborn Memb
Page 19 and 20: • serious impairment to bodily fu
Page 21 and 22: Type of Benefit Description of Bene
Page 23: Type of Benefit Description of Bene
Page 31 and 32: What benefits are not covered? Serv
Page 35 and 36: care is known as routine medical ca
Page 37 and 38: (How Do I Get Medical Care after My
Page 39 and 40: eferral is needed. Only one pair of
Page 41 and 42: You/ your daughter may contact any
Page 45 and 46: 5. Learn about what your health pla
Page 47 and 48: How will I be notified if services
Page 49 and 50: The Member Advocate will listen to

Member Handbook for Parkland KIDSfirst and Parkland CHIP ...

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